The Difficult Patient: Physician writing contest honorable mention

Mrs. Smith refuses this. Mr. Schwartz refuses that. Mr. Johnson is noncompliant with his meds. Ms. Fritsch has been lost to follow-up. Every physician is familiar with the type. I had plenty of experience as a resident with the type. Early in residency, I would passionately counsel every patient, expertly debating with them. I made watertight arguments of how their negligence would ultimately cost them their health. I became good. Really good. I had found a hidden calling; the motivational speaker in me had awakened and was in no mood to be put back to sleep.

Yet many continued to refuse this, refuse that. They continued to be noncompliant, lost to follow-up. What was I doing wrong?

READ MORE:See other winners of the 2015 Physician Writing Contest

With time, my masterful oration was whittled down to short, monotonous lectures. Sure, I had some victories. Mr. Johnson started using an alarm clock to remind him to take his nightly Xalatan. But my talks became more rehearsed. More standard. The motivational speaker in me was in hibernation. It’s not that I stopped trying; I said exactly what I needed to say. My patients understood that they were risking blindness by refusing to follow recommendations. Blindness. Surely, that was scary enough to snap patients into compliance, right?

The story of Mr. Gilmore

During my first year of ophthalmology private practice, I inherited a slew of patients.

When Mr. Gilmore came to see me, he already had a substantial chart: pages upon pages with the word ‘noncompliant’ underlined. New recommendations were made, and it was carefully documented that he had refused each and every one. A few notes had quotations from Mr. Gilmore. The most recent one was scribbled under his ‘chief complaint’: “You all just want to take my money!” It was not the first or last time a patient had complained about their copay.

As most physicians can attest, we truly care about our patients, but there are some who exercise our skill of patience. Mr. Gilmore was that patient for me. I carefully examined his chart and prepared to greet my new patient. As I entered the room, his arms were crossed.

“You the new doctor?” he asked, seemingly harmless.

“Yes, I am,” I answered, treading carefully. I wanted to start off on the right foot.

“So are you also going to rob me blind of all my money?” he hissed. “Oh, and let me save you some time. I’m not starting any of those ridiculous medications!” He became more ornery as the visit progressed, and I stumbled through the rest of it. I gave my standard gentle slap-on-the-wrist reminder that his glaucoma was worsening and that refusing treatment would lead to eventual blindness. He grumbled that he understood, and left without further issue.

He came back for his next visit, and the one after that. For someone who thought we were robbing him blind, he obediently paid each copay and did not miss even one appointment. However, at each visit I felt like a broken record. I recommended, he refused, I counseled, I documented, and he sprinkled in remarks of how ‘darn doctors’ were crooks.

NEXT: "Noncompliance is not a standard diagnosis with a standard treatment"

“Doc, tell me, how much commission do you get from those ridiculous medications you prescribe? You must be making a pretty penny off old people who pay over $100 for those tiny bottles of glaucoma meds!” accused Mr. Gilmore at the third visit.

I was appalled. I was a doctor, not a sneaky salesperson. And what on earth was he even talking about? Commission?! I tabled any discussion of his glaucoma for the moment, and I learned more about Mr. Gilmore than I had at any other visit.

He was an intelligent man who could spew detailed facts about any war and tell you the national language of any country, but somewhere along the way he had gotten the idea that doctors made sales on the medications they prescribed. Surely that was why so many medications were grossly overpriced, he reasoned. When he took his initial prescription to the pharmacy, he was told it would cost him over $100 for a measly 5 mL bottle. Though his insurance did not cover that particular medication, there were plenty of equivalent alternatives that his insurance did cover. However, because he never specifically mentioned the cost of his medication (and no one had inquired), he was not informed of this simple fact.

That same day I switched him to a new medication that cost him less than $10. Though he ultimately needed an additional second agent (which also cost less than $10), as well as a laser procedure to bring him to his goal, my simple discovery had earned me something he did not hand out freely: his trust. My previously cantankerous, noncompliant patient became my star patient, pleasant to deal with and never missing a dose.

The solution to my story seems straightforward and simple enough, but in the fast-paced world of medicine, it is often these easiest fixes that are most frequently overlooked. Did you ask the right questions? Did you miss something?

I had wasted my breath in my early years of training, focusing more on my presentation. I had forgotten the fundamental teaching of medical school: focus on the patient. Take a careful history. Use your exam. Make your diagnosis. Initiate a treatment plan.

Mr. Gilmore had been clear; he was financially constrained. It was physically written on several notes, yet no one had delved further because it was not pertaining to his medical diagnosis. If he had experienced an episode of vision loss, we would have surely asked which eye was affected? Or was it both eyes? How long did it last? What makes it better or worse? The same who, what, when, where, why questions must be asked regarding compliance. What obstacles stand in the way of you taking your medications? Why do you feel that way? What can we do to help?

It is easy to assume that patients do not follow recommendations because they are apathetic or stubborn. However, Mr. Gilmore taught me that noncompliance is not a standard diagnosis with a standard treatment. Like so many disease processes, there are subtypes and categories.

• Shock: cardiogenic, septic, neurogenic, hypovolemic, anaphylactic.

• Glaucoma: open angle, acute angle closure, chronic angle closure, angle recession.

• Noncompliance: due to financial constraints, availability of care, lack of proper education, and the list goes on.

By asking the right questions and initiating a proper plan, physicians can put their patients in a better position to help themselves. It’s about time we start thinking of noncompliance as a potentially treatable condition. As for my patient, Mr. Gilmore, he is happily enjoying remission.

Jihan Akhtar, MD is an ophthalmologist practicing in Merrillville, Indiana.